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WELUP�UMP PERMIT <br /> %AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT% 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT ALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> S c _ ]r m <br /> JOB ADDRESS /� �A/�%]�i CITY/ZIP <br /> CROSS STREET ��/ APN v-! q —0 _ �' 9 <br /> PARCEL S¢E LAND USE APPLICATION k <br /> OWNER NAME HONE <br /> OWNER ADDRESS r AU _ CITY/STATE/ZIP��'�= --FY-�Y • LH �S Z�� <br /> CONTRACTOR '10" CrG.asv _ ___ PHONE 33$4 y7z.s <br /> CONTRACTOR ADDRESS /a cS f��J d' CRY/STATE/LP 4410Q 429414 C4 •_- <br /> SUBCONTRACTOR _�.. PHONE 3 <br /> SUBCONTRACTOR ADDRESS _ _ - CITY/STATE/ZIP _ <br /> LICENSE ) 57 C-61 D-09 Other_ _ NUMBER <br /> 31-Z-jg--- EXPIRATION DATE____ <br /> GEOGRAPHICAL INFORMATION: Coordinates X y Township RangeSection - <br /> INTENDED USE Omestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> P different from Ow ec -Water ys$-dem—ITame —" Dotes ame or a Number -------- <br /> TYPE OF WORK >Lfew Well Xeplacement Well Well Alteration/Modification Other <br /> MonitoringWells U of wells Soil Boring(s)s w of t—ngs r of borings <br /> O -__ 9O— __ Geotechnical <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casio <br /> WELL CONSTRUCTION <br /> Drilling Method7<Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth _�� _ It Excavation,1 z-- - in diameter Open Bottom Gravel Pack/Gravel Size _-_-_—_in diameter <br /> Conductor Casing -- _in diameter / Conductor Casing Depth <br /> Well Casing Diameter tL in Thickness/Gauge/ASTM Sched ZQL_ Steel >Plastic Stainlesss Steel Other <br /> Grout Seal Depth�vb- _ ft Neat Cement(94 lb bag/5-10 gal water) Band Cement (J: sack mixf7 gal Water <br /> Bentonite(209.solids) Other <br /> Grout Placement Method _Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller PUmpContracOther <br /> Concrete Pedestal Dimensions.Widthtor ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP ubmersible Turbine Other Hf> Pump Set IT Standing Water Level If <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, ANC I?ULCS AND REGULATIONS. I ALSO CERTIFY 711AT MY ".EOUMED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED ``,j {/�� _ TITLE KS•_1- DATE__ <br /> ill all— <br /> u J <br /> tENRON E T L <br /> U E A H T M E N T U 9 E ON L Y <br /> Application Accepted By IAKDate v Area _ Employee IDU fvomq <br /> Grout Inspection By _-_ Date �rC[i` I SPECIAL W211 Permit <br /> Pump Inspection By _ Date WAIVER Received <br /> Soil Boring Inspection By Date_ Constructed Well Depth- it <br /> COMMENTS �� � . / ��Hsill _- _!Y_CLt�- j <br /> PE Sc ace ve r Checkit/ Amount Date PermiU Invoice+► Well ID# <br /> Codes Into B Remitted Service Re uest k <br /> 4-70 WELL/PUMP PERMIT <br />